Welcome to the Mad in America podcast, a new weekly discussion that searches for the truth about psychiatric prescription drugs and mental health care worldwide.

This podcast is part of Mad in America’s mission to serve as a catalyst for rethinking psychiatric care. We believe that the current drug-based paradigm of care has failed our society and that scientific research, as well as the lived experience of those who have been diagnosed with a psychiatric disorder, calls for profound change.

On the podcast over the coming weeks, we will have interviews with experts and those with lived experience of the psychiatric system.

Thank you for joining us as we discuss the many issues around rethinking psychiatric care around the world.

On
MIA Radio this week, MIA’s Jessica
Janze interviewed Dr. Jonathan Raskin, in the Department of
Psychology at the State University of New York at New Paltz where
he serves as department chair and teaches classes in psychology and
counselor education.

Dr.
Raskin’s research is focused on constructivist meaning-based
approaches in psychology and counseling. He recently authored a
textbook titled Abnormal Psychology: Contrasting
Perspectives.

Dr.
Raskin describes a recent article he wrote (What Might an
Alternative to the DSM Suitable for Psychotherapists Look Like?)
that highlights psychotherapists’ dissatisfaction with
the Diagnostic and Statistical Manual of Mental Disorders, fifth
edition (DSM-5) and suggests some principles for building
alternative models.

What
follows is a transcript of the interview, edited for
clarity.

****************

JJ: Welcome, Jonathan. I'm very excited
to have you. Is there anything else you want to add about your
background for our readers before we get
started?

JR: No,
not at all. Thank you for inviting me to do this.

JJ: Let's get started. What made
you interested in working on alternative diagnostic systems
for use in psychotherapy?

JR:
Yeah, that's a good question. I've always been interested in how
people make meaning, and diagnostic systems are the way that mental
health professionals make meaning of their client's experiences. So
to me, all diagnostic systems are meaningful systems for making
sense of the problems our clients bring to us.

JJ: You take a constructivist
approach to thinking about diagnosis. Can you break down what that
means for us and how it applies to this issue of
diagnosis?

JR: Many theories fall under the banner of
constructivism, but broadly speaking, constructivism focuses on how
people both individually and in conjunction with one another (and
in more social kinds of configurations) construct understandings of
themselves and the world. Then they use those constructions to
guide their lives. To me, constructivism seems like an
excellent theoretical approach to use in understanding diagnosis
because each diagnostic approach can be viewed as a constructed
meaning system for understanding and conceptualizing client
concerns.

JJ: Several alternative diagnostic
systems have been promoted in recent years, including HiTop, the
Power Threat Meaning framework, RDoC, and the PDM. What are your
thoughts on these alternatives?

JR: I think they're all interesting in
their own ways. Let me talk about a few of them. I'll start with
HiTop. That's the hierarchical taxonomy of psychopathology. It's a
dimensional approach that tries to address the problem of
comorbidity that afflicts DSM categories. Comorbidity is a
confusing issue for people. When disorders are comorbid,
they're diagnosed at the same time. One of the problems is that a
lot of the DSM diagnoses are comorbid with one another. If you have
too much comorbidity, the question that arises is, are the
categories that we've constructed distinct from one
another?

HiTop
thinks that comorbidity should be embraced instead
of rejected. They say, “Yes, these DSM categories cluster
together, we can group each of them under these broader spectrums.”
The HiTop system uses six spectrum dimensions. Ultimately, the
people who created HiTop feel that DSM disorders might be
discardable, but for the time being, we can keep them.

They
say that there are really these co-morbid overlapping categories
underneath these higher levels, six distinct spectra. HiTop sees
this as a simpler approach because you can divide people's problems
into how they score along these six different spectrum dimensions.
It's still very early going. I think it has a lot in common with
the big five personality research. If you like those, you'll like
HiTop. If you don't like those, you might not be a fan of
HiTop.

Let me
talk a little bit about RDoC. RDoC is the research domain
criteria system. It's a research initiative at the moment. It's not
a diagnostic system yet. They're trying to build a diagnostic
system from the ground up, and they're doing that by trying to
identify the ways that the brain is designed to function. Then, and
only then, they will identify ways that it malfunctions. And so the
categories that they create will be based on their identifying and
diagnosing these specific malfunctions.

The
people involved in RDoC say, “We're doing this in the right way,
whereas the DSM does it backward.” DSM starts with categories and
then researchers race around trying to find out what the biological
correlates of those categories are. RDoC says, “Let's understand
the brain and how it works and then build categories based on
observable differences between healthy and unhealthy brains.” It's
a very medical model kind of approach. And if you like that, you'll
like RDoC. If you don't like the medical model, you
won't.

What's
really fascinating about [RDOC] is the idea that it wants to build
the system from the ground up. It is not yet a diagnostic system;
it's a research initiative. We don't have the ability to identify
any kind of presenting problems based exclusively on these kinds of
biological biomarkers just yet.

Then
there's the Power Threat Meaning framework (PTM), which is going
180 degrees in the other direction. PTM shifts the focus. It moves
away from the medical model. It actually doesn't consider itself a
diagnostic system. It rejects the idea of medical model diagnostic
systems. It says that we need to depathologize people's problems by
focusing on what the PTM identifies as the actual causes. It says
that economic and social injustices are the root causes of
emotional distress. The origins of distress lie outside the person.
RDOC looks inside the person, and I think the DSM, in many
respects, implies that it's inside the person. PTM emphasizes what
has happened to people on a socio-cultural level and then how
they've responded to it. It's a totally different approach. It's a
non-diagnostic approach.

Another
approach is the Psychodynamic Diagnostic Manual (PDM). From its
name, you can tell it’s an explicitly psychodynamic diagnostic
manual that diagnoses problems through the lens of psychodynamic
theory. So whereas the DSM has traditionally been atheoretical, in
the sense that it's a descriptive, diagnostic manual describing
problems, but it doesn't take a stance on what causes them, the PDM
roots its approach explicitly in psychodynamic theory.

All of
these approaches are really interesting in their own way. The
question is whether or not they'll catch on.

JJ: You don't think that there is one
particular diagnostic system that our society should switch to, is
that correct?

JR: I view diagnostic systems as tools.
Like hammers, they're really helpful instruments. However,
depending on the task I’m up to, I might be better off with a
wrench or a pair of pliers or some other tool instead. So, I find
it helpful to use the tools metaphor when considering diagnostic
systems.

One
might find a given diagnostic system useful, or not, depending on
the situation. Of course, it's always important to remember that
diagnostic systems provide maps that can guide us, but we have to
be careful not to mistake the map for the territory.

I think
the biggest barrier to developing viable alternatives to the DSM
and the ICD is that these approaches cross theoretical perspectives
by being mainly descriptive. But, when it comes to how a diagnostic
system informs treatment, descriptive approaches, in many ways are
lacking. That is, they don't take any stance on how to best
approach the problems they identify or describe. So, their wanting
to script nature makes DSM and ICD easy for everyone to adopt
regardless of the theoretical viewpoint. But any theoretically
driven system, things like the PDM or the power threat meaning
framework or RDoC even, those systems in many ways might struggle
to gain mass acceptance because their theoretical commitments will
turn people off.

Somebody who doesn't like a medical model brain
approach won't use RDoC. Somebody who's really opposed to
psychodynamic theories, or just not interested in them, won't use
PDM. Somebody who doesn't take a social justice orientation to
problems might not like PTM. By being theoretically well developed
and informative about how to conceptualize and approach client
problems, these alternative diagnostic systems ironically make
themselves less broadly appealing. That can be a challenge for
them. But, if they are tools you don't have to stick with just one,
you could jump around from one system to the next depending on what
you're up to that day.

JJ: What about insurance companies?
What do you think an alternative to the DSM system that could be
used for insurance purposes would look like?

JR: I’m not sure. It’s been suggested by a
lot of people that a very practical thing we can do is use the
DSM-5 V codes (which list circumstances or experiences, such
as "Homelessness," "Poverty," and "High Expressed Emotion Level
Within Family") because that might let us identify presenting
problems while being less medicalizing and stigmatizing.

Practically, those codes already exist, but we
would need insurers to cover them for clinicians to begin using
them. One of the reasons they don't get used is that insurance
companies don't cover the code diagnosis. As I was describing a
minute ago, I think theoretically coherent systems might prove to
be more helpful to clinicians in a practical, everyday manner but
they're less likely to be appreciated and used across clinicians
and different theoretical orientations. That's the challenge. Being
theoretically consistent and pure and developing something that a
smaller group of people might like to use versus having something
that would kind of cut across all theoretical orientations. The
latter might be more descriptive, but potentially not the most
clinically useful, but would help grease the wheels of
insurance.

JJ: Can you talk more about the
importance of including service users and people with lived
experiences in the development of any future
alternatives?

JR: I think it's very important to listen
to service users because they're the ones impacted by whatever
diagnostic system we develop and use. So we really need their
feedback, especially if we want to avoid inadvertently harming
them.

JJ: How do you think diagnoses
should be approached in therapy? How do you recommend clinicians
approach these topics with people who come to see
them?

JR: I think we often draw sort of an
artificial line between diagnosis and treatment. George Kelly was
the psychologist who developed personal construct theory, and he
used to say that therapists have to continually revise their
understandings of clients because clients are always in process and
forever changing. That's why Kelly used the term transitive
diagnosis. He said diagnoses are transitive because they are
continually evolving.

So
given that, regardless of the diagnostic approach that a therapist
takes, it seems to me very important for the therapist to not reify
the diagnosis made because I think doing so locks the client in
place in a way that can be highly limiting. That would be true
across different diagnostic systems for me. Whichever system
somebody’s adopting, you have to be careful not to be too literal
or reifying about that system. So to me, thinking of diagnoses as
meaningful constructions, as created understandings that
might -for the time being- inform what we're doing, is
terrific. But when we shift to seeing them as essential,
unchangeable things we can lock ourselves in, and we can actually
also unintentionally harm the people we're working with.

JJ: More of a living
system.

JR: As Kelly said, you have to keep up with
your clients. They're always in process, and you better keep up
with them because if you're still using last week's a
conceptualization and understanding, well, they may have moved
on.

JJ: Is there anything else that you
wanted to add or talk to us about before we wrap
up?

JR: No, I mean just that I think this is a
growing area that people are expressing interest in. I sense that a
lot of clinicians don't really know much about different
alternatives beyond the DSM and the ICD. And so, one of the things
that I've been interested in recently is just helping the field
have more knowledge; helping the clinicians out in the field
become aware of approaches that they may not know much
about.

My
sense is that clinicians are hungry for alternatives, but they
don't necessarily know what the alternatives are. And then, at the
same time, they also feel trapped in the sense that in order for
them to get paid, they need to use the DSM. But it doesn’t mean,
even if the issues of reimbursement haven't been resolved for other
systems, it doesn't mean that they can't learn about and begin
using these other systems in addition. It doesn't have to be an
either-or. So my goal is to learn more about these
diagnostic alternatives myself and then to help others out in the
field learn about them as well.

JJ: I think that's really great.
Just talking about alternatives and getting the information out
even if we do not necessarily subscribe to them or use
them.

JR: Having an open discussion and dialogue
about them is important, and I think people are very quick to make
judgments about which approach they like or dislike. But I think if
you want to develop alternatives, you have to be open-minded and be
willing to talk with people who might be developing alternatives
that are very different from what you yourself might develop and
appreciate that each alternative may have advantages to it as well
as disadvantages.

JJ: I'm excited to see these
theories evolve and to see how the field continues this
conversation and I'm glad that you're a part of that. Your textbook
compares and lays out the alternative diagnostic frameworks,
right?

JR: Yea, one of the things that I was very
excited to do in the book was to present alternative perspectives
across both diagnosis and treatment interventions. In the diagnosis
chapter, I talk about RDoC; I talk about HiTop; I talk about the
PTM framework; Because I think it's essential for students in the
field to learn about these approaches. If we want to disseminate
information about them, we have to cover them in the places where
students are learning about them.

I also
spend a lot of time on DSM and ICD because those are the most
influential approaches today. So all of them get covered, and they
get covered as perspectives. Each one is a diagnostic perspective
that a person might adopt depending on what the goal is in the
given moment.

JJ: Well I have to say, I really
appreciate you doing this work. I appreciate your perspectives. I
appreciate you coming on today and sharing this information with
our readers. I do agree with you. I think it's so important to get
this information out to people. Thank you so much for talking to
us, and I look forward to hearing more about your
work.

About the Podcast

Welcome to the Mad in America podcast, a new weekly discussion that searches for the truth about psychiatric prescription drugs and mental health care worldwide.
This podcast is part of Mad in America’s mission to serve as a catalyst for rethinking psychiatric care and mental health. We believe that the current drug-based paradigm of care has failed our society and that scientific research, as well as the lived experience of those who have been diagnosed with a psychiatric disorder, calls for profound change.
On the podcast over the coming weeks, we will have interviews with experts and those with lived experience of the psychiatric system. Thank you for joining us as we discuss the many issues around rethinking mental health around the world.
For more information visit madinamerica.com
To contact us email podcasts@madinamerica.com